Highmark Health Jobs

This job is directly responsible for outcomes of providers contracted in the Organization's gain/risk share arrangements and is a highly skilled expert in practice transformation to achieve the specific targets set in the individual gain/risk share contracts and is strategically focused on those data gaps that will result in the greatest ROI for the Organization. Further, in a matrix management environment, will be responsible for collaborative work with the other members of the value-based reimbursement team, provider relations, senior markets, analytics, actuary and key internal/external stake holders to provide the most appropriate support for providers with gain/risk share contracts.

ESSENTIAL RESPONSIBILITIES

Directly responsible for supporting providers contracted in the Organization's gain/risk share programs, with a goal of maximizing quality and ROI for the Organization. This includes analyzing performance reports and data to inform decision-making, process, and program implementation, as well as the development of process interventions based on practice-level data, trends and identified opportunities. Inclusive of, but not limited to:Advising primary care practices, physicians, nurses and other clinical staff to assist them on their conversion to value-based care; Dissemination and interpretation of quality and efficiency reports; When relevant, dissemination and support of gap closures for STARS and improved coding for government populations.Identification of process improvement gaps in workflow and development of individualized plans to remedy.Providing educational and training sessions. Creation and maintenance of relationships with specialists and/or hospital resources for providers employed in multi specialty groups or health systems.

For value based contracts addressing government markets, directly responsible for the quality improvement and cost savings outcomes as a result of workflow transformation, superior coding accuracy, and Medicare STARS gap closure to providers based upon each individual gain/risk share contract parameters.This includes analysis and interpretation of claims submission for superior coding accuracy, cost and utilization reports, medical loss ratio reports, Medicare STARS gaps and other risk revenue opportunities.

Function as the Organization's key contact on gain/risk share multi-disciplinary team.This includes presentation of program results to both internal and external audiences, including practice and entity meetings with the value-based reimbursement multi-disciplinary team

Participates in the development and presentation of instructional materials for internal and external audiences.

Provides feedback to and collaborates with the analytics team to ensure reports are accurate, and provide meaningful, actionable data. Provide assistance to providers in the use of predictive analytic tools, user interfaces, population health management tools and other data based platforms endorsed by the Organization.

Must be able to effectively resolve issues and problems across all areas of the corporation, by understanding corporate strategies, policy and scope of authority

Because of the broad impact of decisions that are made, must be knowledgeable and sensitive to many internal and external corporate issues

Aptitude for a high visibility position demanding integrity, uncompromising professionalism, diplomacy and conflict management

Demonstrates a deep understanding of primary care practice operations and workflow across the continuum of variability in primary care and experience in managing provider and administrative leadership relationships